Change How Serious Incidents are Investigated by the NHS
Sign our Petition in support of Jessica Rae Rudland and help to change the legislation so that we, the people have more control when a loved one or family member receives an injury. If you would like to support a change to how Serious Incidents Requiring Investigation (SIRI’s) are investigated in all NHS organisations, please click the picture to visit the change.org website which is hosting our Petition.
The Facts – Every day hundreds of Serious Incidents occur within NHS provider organisations. You as an individual, a person are the service user and expect to receive the appropriate, safe and effective care from the provider.
The Code of Ethics – The professionals who help and care for you are legislated by a code of ethics, there are medical councils in the United Kingdon, namely The General Medical Council (GMC) Doctors have to report when things go wrong for patients, for example, accidents and mistakes, or when patients get serious side effects from medicines so lessons can be learned.
Raising Concerns – They must make sure they tell colleagues about any suspected side effects from medicines they have given, or if there is anything else they are concerned about. The Nursing and Midwifery Council (NMC) who oversee (The Code) mention in their Professional standards of practice and behaviour for nurses and midwives in 14.1 act immediately to put right the situation if someone has suffered actual harm for any reason or an incident has happened which had the potential for harm.
The Medical Professionals have chosen this career, they should act responsibly and be accountable for their actions. They should take care of patients in accordance with the Good medical practice: Explanatory guidance.
When Serious Incidents happen, they are still investigated internally even when Serious Harm and Death has occurred including long-term Brain Injury as in Jessica’s case.
The changes we propose – are all Serious Incidents are investigated Independently of the NHS organisation where the incident happened. In the aeronautical industry as in the NTSB and UK Police investigations like IPCC. The evidence is gathered consistently and proactively to ensure critical forensic evidence is secured. In Jessica’s case, much of the data from equipment she was connected to was lost, clinical/medical notes were not secured or obtained in a timely fashion. All those involved in Jessica’s treatment and care were not contacted or formally interviewed.
- NHS providers investigations must be scrutinised by external expert investigators, other than their own commissioners (CCG)
- NHS providers must communicate with patients, families and carers using a single family liaison officer throughout any investigation
- NHS providers must secure and collect all evidence. Include all those involved and collect dated formal interviews and serious incident statements
- NHS providers investigations must include independent clinical specialists from outside the area where the incident occurred
- NHS providers should adopt a forensic analysis and ‘lockdown’ at the scene of any serious incident where patient harm has occurred
- NHS providers must no longer be able to review their own SIRI findings, then make amendments to produce a bias report in their favour
- NHS providers must at all times adopt root cause analysis (RCA) methodology for investigations and provide a comprehensive detailed report
- NHS providers must be open and transparent and be monitored by an external body to ensure compliance (Duty of Candour)
- NHS providers must publish serious incident report findings and outcomes, anonymised but openly demonstrate resolution and conclusion status
Our daughter Jessica received four hours of intensive treatment in The Ipswich Hospital’s A & E Department for what was described as an Arrhythmia, recently pregnant. During a two year period involving many questions and scrutiny from the family, the Ipswich Hospital has not addressed all our questions and we believe the investigation process needs to change urgently to safeguard other service users.